Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Overview of contraception

Mimi Zieman, MD
Section Editor
Robert L Barbieri, MD
Deputy Editor
Kristen Eckler, MD, FACOG


Individuals choose to use contraception for many reasons:

All contraceptives provide control over the timing of pregnancy and avoidance of unintended pregnancy

Condoms provide protection from sexually transmitted infections

Hormonal contraceptives provide noncontraceptive health benefits (table 1)

A systematic review estimated contraceptive prevalence among women of reproductive age who were married or in a union was 63 percent worldwide and 77 percent in the United States [1]. Nevertheless, unintended pregnancy is a common problem. In a study from the Guttmacher Institute using data from several sources, 49 percent of the 6.7 million pregnancies in the United States in 2006 were unintended [2]. About 5 percent of women of reproductive age had an unintended pregnancy that year, comprising 3.2 million pregnancies. The demographic characteristics of these women are shown in the table (table 2). Forty-three percent of the unintended pregnancies were terminated. These alarmingly high statistics occurred even though most women reported using some form of contraception [3]. The high rate of unintended pregnancy despite contraception highlights the importance of understanding contraceptive efficacy in terms of typical, rather than perfect, use (see 'Effectiveness' below).


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jan 2016. | This topic last updated: Jul 22, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Alkema L, Kantorova V, Menozzi C, Biddlecom A. National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis. Lancet 2013; 381:1642.
  2. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception 2011; 84:478.
  3. Kost K, Singh S, Vaughan B, et al. Estimates of contraceptive failure from the 2002 National Survey of Family Growth. Contraception 2008; 77:10.
  4. Nettleman MD, Chung H, Brewer J, et al. Reasons for unprotected intercourse: analysis of the PRAMS survey. Contraception 2007; 75:361.
  5. Montouchet C, Trussell J. Unintended pregnancies in England in 2010: costs to the National Health Service (NHS). Contraception 2013; 87:149.
  6. Trussell J, Henry N, Hassan F, et al. Burden of unintended pregnancy in the United States: potential savings with increased use of long-acting reversible contraception. Contraception 2013; 87:154.
  7. Trussell J, Lalla AM, Doan QV, et al. Cost effectiveness of contraceptives in the United States. Contraception 2009; 79:5.
  8. Burlone S, Edelman AB, Caughey AB, et al. Extending contraceptive coverage under the Affordable Care Act saves public funds. Contraception 2013; 87:143.
  9. Moreau C, Cleland K, Trussell J. Contraceptive discontinuation attributed to method dissatisfaction in the United States. Contraception 2007; 76:267.
  10. Grunloh DS, Casner T, Secura GM, et al. Characteristics associated with discontinuation of long-acting reversible contraception within the first 6 months of use. Obstet Gynecol 2013; 122:1214.
  11. Trussell J. Contraceptive failure in the United States. Contraception 2011; 83:397.
  12. Steiner MJ. Contraceptive effectiveness: what should the counseling message be? JAMA 1999; 282:1405.
  13. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2011; 118:184.
  14. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012; 366:1998.
  15. Harper CC, Rocca CH, Thompson KM, et al. Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial. Lancet 2015; 386:562.
  16. Reducing unintended teen pregnancy in Colorado https://www.colorado.gov/pacific/sites/default/files/HPF_FP_UP-Reducing-Teen-Pregnancy.pdf (Accessed on July 06, 2015).
  17. Trussell J, Wynn LL. Reducing unintended pregnancy in the United States. Contraception 2008; 77:1.
  18. Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012; 120:1291.
  19. Trussell J, Hatcher RA, Cates W Jr, et al. A guide to interpreting contraceptive efficacy studies. Obstet Gynecol 1990; 76:558.
  20. Lopez LM, Steiner M, Grimes DA, et al. Strategies for communicating contraceptive effectiveness. Cochrane Database Syst Rev 2013; 4:CD006964.
  21. US Selected Practice Recommendations for Contraceptive Use, 2013. http://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf. (Accessed on June 14, 2013).
  22. Blish CA, Baeten JM. Hormonal contraception and HIV-1 transmission. Am J Reprod Immunol 2011; 65:302.
  23. Morrison CS, Chen PL, Kwok C, et al. Hormonal contraception and the risk of HIV acquisition: an individual participant data meta-analysis. PLoS Med 2015; 12:e1001778.
  24. Tepper NK, Curtis KM, Steenland MW, Marchbanks PA. Blood pressure measurement prior to initiating hormonal contraception: a systematic review. Contraception 2013; 87:631.
  25. Stewart FH, Harper CC, Ellertson CE, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. JAMA 2001; 285:2232.
  26. Tepper NK, Curtis KM, Steenland MW, Marchbanks PA. Physical examination prior to initiating hormonal contraception: a systematic review. Contraception 2013; 87:650.
  27. Clinical Effectiveness Unit. Combined hormonal contraception. London (UK): Faculty of Sexual and Reproductive Healthcare; 2011 Oct. 28 http://guideline.gov/content.aspx?f=rss&id=36071 (Accessed on June 25, 2012).
  28. Bracken MB. Oral contraception and congenital malformations in offspring: a review and meta-analysis of the prospective studies. Obstet Gynecol 1990; 76:552.
  29. Jellesen R, Strandberg-Larsen K, Jørgensen T, et al. Maternal use of oral contraceptives and risk of fetal death. Paediatr Perinat Epidemiol 2008; 22:334.
  30. WHO Medical eligibility criteria for contraceptive use. Fourth edition, 2009. http://whqlibdoc.who.int/publications/2010/9789241563888_eng.pdf. (Accessed on June 11, 2012).
  31. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report (MMWR). U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. Adapted from the World Health Organization Medical Eligibility Criteria for Contraceptive Use, 4th edition. Early release - May 28, 2010. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr59e0528a1.htm (Accessed on May 28, 2010).
  32. Patel A, Schwarz EB, Society of Family Planning. Cancer and contraception. Release date May 2012. SFP Guideline #20121. Contraception 2012; 86:191.
  33. Kuohung W, Borgatta L, Stubblefield P. Low-dose oral contraceptives and bone mineral density: an evidence-based analysis. Contraception 2000; 61:77.
  34. Lopez LM, Grimes DA, Schulz KF, Curtis KM. Steroidal contraceptives: effect on bone fractures in women. Cochrane Database Syst Rev 2009; :CD006033.
  35. van den Heuvel MW, van Bragt AJ, Alnabawy AK, Kaptein MC. Comparison of ethinylestradiol pharmacokinetics in three hormonal contraceptive formulations: the vaginal ring, the transdermal patch and an oral contraceptive. Contraception 2005; 72:168.
  36. Milsom I, Korver T. Ovulation incidence with oral contraceptives: a literature review. J Fam Plann Reprod Health Care 2008; 34:237.
  37. Westhoff C, Heartwell S, Edwards S, et al. Initiation of oral contraceptives using a quick start compared with a conventional start: a randomized controlled trial. Obstet Gynecol 2007; 109:1270.
  38. Foster DG, Parvataneni R, de Bocanegra HT, et al. Number of oral contraceptive pill packages dispensed, method continuation, and costs. Obstet Gynecol 2006; 108:1107.
  39. Steenland MW, Zapata LB, Brahmi D, et al. Appropriate follow up to detect potential adverse events after initiation of select contraceptive methods: a systematic review. Contraception 2013; 87:611.
  40. Barnhart KT, Schreiber CA. Return to fertility following discontinuation of oral contraceptives. Fertil Steril 2009; 91:659.
  41. Mansour D, Gemzell-Danielsson K, Inki P, Jensen JT. Fertility after discontinuation of contraception: a comprehensive review of the literature. Contraception 2011; 84:465.
  42. Farrow A, Hull MG, Northstone K, et al. Prolonged use of oral contraception before a planned pregnancy is associated with a decreased risk of delayed conception. Hum Reprod 2002; 17:2754.
  43. Allen RH, Cwiak CA, Kaunitz AM. Contraception in women over 40 years of age. CMAJ 2013; 185:565.
  44. Hillard PJ, Berek JS, Barss VA, et al. Guidelines for women’s health care: a resource manual. 3rd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2007.
  45. The North American Menopause Society. Prescription hormonal therapies. Menopause practice: a clinician’s guide. 4th ed. 2010.
  46. Sitruk-Ware R, Plu-Bureau G, Menard J, et al. Effects of oral and transvaginal ethinyl estradiol on hemostatic factors and hepatic proteins in a randomized, crossover study. J Clin Endocrinol Metab 2007; 92:2074.
  47. Tourgeman DE, Slater CC, Stanczyk FZ, Paulson RJ. Endocrine and clinical effects of micronized estradiol administered vaginally or orally. Fertil Steril 2001; 75:200.
  48. Goebelsmann U, Mashchak CA, Mishell DR Jr. Comparison of hepatic impact of oral and vaginal administration of ethinyl estradiol. Am J Obstet Gynecol 1985; 151:868.
  49. Nath A, Sitruk-Ware R. Progesterone vaginal ring for contraceptive use during lactation. Contraception 2010; 82:428.
  50. Massai R, Miranda P, Valdés P, et al. Preregistration study on the safety and contraceptive efficacy of a progesterone-releasing vaginal ring in Chilean nursing women. Contraception 1999; 60:9.
  51. Jain J, Dutton C, Nicosia A, et al. Pharmacokinetics, ovulation suppression and return to ovulation following a lower dose subcutaneous formulation of Depo-Provera. Contraception 2004; 70:11.
  52. Gallo MF, Grimes DA, Lopez LM, et al. Combination injectable contraceptives for contraception. Cochrane Database Syst Rev 2008; :CD004568.
  53. Population Council. Jadelle® Implants Frequently Asked Questions. www.popcouncil.org/biomed/jadellefaqgeninfo.html (Accessed on March 07, 2005).
  54. Sivin I, Wan L, Ranta S, et al. Levonorgestrel concentrations during 7 years of continuous use of Jadelle contraceptive implants. Contraception 2001; 64:43.
  55. Wan LS, Stiber A, Lam LY. The levonorgestrel two-rod implant for long-acting contraception: 10 years of clinical experience. Obstet Gynecol 2003; 102:24.
  56. Hubacher D, Lopez L, Steiner MJ, Dorflinger L. Menstrual pattern changes from levonorgestrel subdermal implants and DMPA: systematic review and evidence-based comparisons. Contraception 2009; 80:113.
  57. Steiner MJ, Lopez LM, Grimes DA, et al. Sino-implant (II)--a levonorgestrel-releasing two-rod implant: systematic review of the randomized controlled trials. Contraception 2010; 81:197.
  58. Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial. Contraception 1994; 49:56.
  59. Sivin I. Dose- and age-dependent ectopic pregnancy risks with intrauterine contraception. Obstet Gynecol 1991; 78:291.
  60. Mol BW, Ankum WM, Bossuyt PM, Van der Veen F. Contraception and the risk of ectopic pregnancy: a meta-analysis. Contraception 1995; 52:337.
  61. Raymond EG, Halpern V, Lopez LM. Pericoital oral contraception with levonorgestrel: a systematic review. Obstet Gynecol 2011; 117:673.
  62. Halpern V, Raymond EG, Lopez LM. Repeated use of pre- and postcoital hormonal contraception for prevention of pregnancy. Cochrane Database Syst Rev 2014; 9:CD007595.
  63. Ortiz ME, Croxatto HB. The mode of action of IUDs. Contraception 1987; 36:37.
  64. Gallo MF, Grimes DA, Schulz KF. Cervical cap versus diaphragm for contraception. Cochrane Database Syst Rev 2002; :CD003551.
  65. Kuyoh MA, Toroitich-Ruto C, Grimes DA, et al. Sponge versus diaphragm for contraception. Cochrane Database Syst Rev 2002; :CD003172.
  66. Schwartz B, Gaventa S, Broome CV, et al. Nonmenstrual toxic shock syndrome associated with barrier contraceptives: report of a case-control study. Rev Infect Dis 1989; 11 Suppl 1:S43.
  67. Ranjit N, Bankole A, Darroch JE, Singh S. Contraceptive failure in the first two years of use: differences across socioeconomic subgroups. Fam Plann Perspect 2001; 33:19.
  68. Dude A, Neustadt A, Martins S, Gilliam M. Use of withdrawal and unintended pregnancy among females 15-24 years of age. Obstet Gynecol 2013; 122:595.
  69. The World Health Organization multinational study of breast-feeding and lactational amenorrhea. III. Pregnancy during breast-feeding. World Health Organization Task Force on Methods for the Natural Regulation of Fertility. Fertil Steril 1999; 72:431.
  70. Kennedy KI, Rivera R, McNeilly AS. Consensus statement on the use of breastfeeding as a family planning method. Contraception 1989; 39:477.
  71. Shaaban OM, Glasier AF. Pregnancy during breastfeeding in rural Egypt. Contraception 2008; 77:350.
  72. Raymond EG, Trussell J, Weaver MA, Reeves MF. Estimating contraceptive efficacy: the case of spermicides. Contraception 2013; 87:134.
  73. Raymond EG, Chen PL, Luoto J, Spermicide Trial Group. Contraceptive effectiveness and safety of five nonoxynol-9 spermicides: a randomized trial. Obstet Gynecol 2004; 103:430.
  74. Schreiber CA, Meyn LA, Creinin MD, et al. Effects of long-term use of nonoxynol-9 on vaginal flora. Obstet Gynecol 2006; 107:136.
  75. Roddy RE, Zekeng L, Ryan KA, et al. Effect of nonoxynol-9 gel on urogenital gonorrhea and chlamydial infection: a randomized controlled trial. JAMA 2002; 287:1117.
  76. Kreiss J, Ngugi E, Holmes K, et al. Efficacy of nonoxynol 9 contraceptive sponge use in preventing heterosexual acquisition of HIV in Nairobi prostitutes. JAMA 1992; 268:477.
  77. Roddy RE, Zekeng L, Ryan KA, et al. A controlled trial of nonoxynol 9 film to reduce male-to-female transmission of sexually transmitted diseases. N Engl J Med 1998; 339:504.
  78. Richardson BA, Lavreys L, Martin HL Jr, et al. Evaluation of a low-dose nonoxynol-9 gel for the prevention of sexually transmitted diseases: a randomized clinical trial. Sex Transm Dis 2001; 28:394.
  79. Van Damme L, Ramjee G, Alary M, et al. Effectiveness of COL-1492, a nonoxynol-9 vaginal gel, on HIV-1 transmission in female sex workers: a randomised controlled trial. Lancet 2002; 360:971.
  80. Niruthisard S, Roddy RE, Chutivongse S. The effects of frequent nonoxynol-9 use on the vaginal and cervical mucosa. Sex Transm Dis 1991; 18:176.
  81. Einarson TR, Koren G, Mattice D, Schechter-Tsafriri O. Maternal spermicide use and adverse reproductive outcome: a meta-analysis. Am J Obstet Gynecol 1990; 162:655.
  82. Gallaway MS, Waller DK, Canfield MA, et al. The association between use of spermicides or male condoms and major structural birth defects. Contraception 2009; 80:422.
  83. Abbott J. Transcervical sterilization. Curr Opin Obstet Gynecol 2007; 19:325.
  84. Lippes J. Quinacrine sterilization: the imperative need for american clinical trials. Fertil Steril 2002; 77:1106.
  85. Lippes J, Brar M, Gerbracht K, et al. An FDA phase I clinical trial of quinacrine sterilization (QS). Int J Gynaecol Obstet 2003; 83 Suppl 2:S45.
  86. Informed Consent Working Group. Quinacrine sterilization (QS): informed consent. Int J Gynaecol Obstet 2003; 83 Suppl 2:S147.
  87. Merchant RN, Doctor VM, Thaku SS, et al. Clinico-pathological study of fallopian tubes after transcervical insertion of quinacrine hydrochloride pellets. Adv Contracept 1986; 2:79.
  88. el Sahwi S, Kamel M, el Faham M, el Makhzangy I. Hysteroscopic and hysterosalpingographic study after intrauterine insertion of quinacrine pellets for non-surgical sterilization: results in 180 women. Int J Gynaecol Obstet 2003; 83 Suppl 2:S101.
  89. Sokal DC, Hieu do T, Loan ND, et al. Safety of quinacrine contraceptive pellets: results from 10-year follow-up in Vietnam. Contraception 2008; 78:66.
  90. Sokal DC, Trujillo V, Guzmán SC, et al. Cancer risk after sterilization with transcervical quinacrine: updated findings from a Chilean cohort. Contraception 2010; 81:75.
  91. Sokal DC, Hieu do T, Loan ND, et al. Contraceptive effectiveness of two insertions of quinacrine: results from 10-year follow-up in Vietnam. Contraception 2008; 78:61.
  92. Soroodi-Moghaddam S. Quinacrine sterilization (QS) in Iran and the use of HSG as a measure of success. Int J Gynaecol Obstet 2003; 83 Suppl 2:S93.
  93. Cancel AM, Dillberger JE, Kelly CM, et al. A lifetime cancer bioassay of quinacrine administered into the uterine horns of female rats. Regul Toxicol Pharmacol 2010; 56:156.
  94. Sokal DC, Vach TH, Nanda K, et al. Quinacrine sterilization and gynecologic cancers: a case-control study in northern Vietnam. Epidemiology 2010; 21:164.
  95. Australasian Menopause Society. Contraception for women approaching menopause. http://www.menopause.org.au/consumers/information-sheets/24 (Accessed on November 14, 2011).
  96. http://www.patient.co.uk/doctor/Contraception-and-the-Mature-Woman.htm (Accessed on November 14, 2011).
  97. ESHRE Capri Workshop Group. Female contraception over 40. Hum Reprod Update 2009; 15:599.
  98. Naz RK, Gupta SK, Gupta JC, et al. Recent advances in contraceptive vaccine development: a mini-review. Hum Reprod 2005; 20:3271.
  99. Grimes DA, Lopez LM, Gallo MF, et al. Steroid hormones for contraception in men. Cochrane Database Syst Rev 2012; 3:CD004316.
  100. Page ST, Amory JK, Anawalt BD, et al. Testosterone gel combined with depomedroxyprogesterone acetate is an effective male hormonal contraceptive regimen and is not enhanced by the addition of a GnRH antagonist. J Clin Endocrinol Metab 2006; 91:4374.
  101. Cummings DE, Kumar N, Bardin CW, et al. Prostate-sparing effects in primates of the potent androgen 7alpha-methyl-19-nortestosterone: a potential alternative to testosterone for androgen replacement and male contraception. J Clin Endocrinol Metab 1998; 83:4212.
  102. Suvisaari J, Moo-Young A, Juhakoski A, et al. Pharmacokinetics of 7 alpha-methyl-19-nortestosterone (MENT) delivery using subdermal implants in healthy men. Contraception 1999; 60:299.
  103. Attardi BJ, Hild SA, Reel JR. Dimethandrolone undecanoate: a new potent orally active androgen with progestational activity. Endocrinology 2006; 147:3016.
  104. Bebb RA, Anawalt BD, Christensen RB, et al. Combined administration of levonorgestrel and testosterone induces more rapid and effective suppression of spermatogenesis than testosterone alone: a promising male contraceptive approach. J Clin Endocrinol Metab 1996; 81:757.
  105. Gu YQ, Tong JS, Ma DZ, et al. Male hormonal contraception: effects of injections of testosterone undecanoate and depot medroxyprogesterone acetate at eight-week intervals in chinese men. J Clin Endocrinol Metab 2004; 89:2254.
  106. Grimes DA, Lopez LM, Gallo MF, et al. Steroid hormones for contraception in men. Cochrane Database Syst Rev 2007; :CD004316.
  107. Gonzalo IT, Swerdloff RS, Nelson AL, et al. Levonorgestrel implants (Norplant II) for male contraception clinical trials: combination with transdermal and injectable testosterone. J Clin Endocrinol Metab 2002; 87:3562.
Topic Outline